ACCESSIBILITY

The first step towards a beautiful, healthy smile is scheduling your appointment!

We have made requesting an appointment a simple process on our website for your convenience.

Please contact our office by completing the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment shortly. You are also welcome to reach the office by phone at 319.365.4997

IMPORTANT: Please do not use this form to cancel or change an existing appointment. 

If, for any reason you cannot keep a scheduled appointment, please call us with at least 24 hours notice. If you will be delayed, please let us know as soon as possible.

 


Items in bold are required.
Name:  
Address:
City:
State/Province:
Zip/Postal:
Phone:
Email:
Are you a current patient?
Best time(s) to call?
Preferred day(s) of the week for an appointment?
Preferred time(s) for an appointment?
Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
 
 

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.